Clinical diagnosis
My clinical diagnosis is primary Adhesive Capsulitis (“frozen shoulder”). The
information gathered that supports this hypothesis is featured below:
Area of symptoms: The patient presented with deep posterosuperior shoulder
pain and associated chronic stiffness. Pain in this region, decreases the
likelihood of a rotator cuff (RC) lesion or AC joint pathology, as both typically
present with anterior/lateral pain.(1,2) Adhesive capsulitis is a likely diagnosis
as it produces a deep pain that can radiate into the deltoid insertion OR
posterior shoulder and is associated with chronic stiffness.(3,4,5) The sharp
pain quality is contradictory to the dull, achy pain typically experienced with
RC tear and OA.(2) Pins and needles in the fingertips are likely to have been
an acute response to initial trauma (possible brachial plexus traction from
pulling of arm) however, as they disappeared shortly after the trauma, the
symptom is no longer relevant to the current pathology. Therefore, a
neurological examination is not required.
Behaviour of symptoms: Pain is elicited in overhead (flexion), behind-back
(internal rotation) and external rotation movement. In combination with night
pain, these descriptions support the Dx. Rapid, sharp pain reported
specifically at end range of the aggravating movements suggests a capsular
rather than extra-articular limitation.(3,7,8) Swift decreases in pain when the
capsule is taken off stretch indicates a non-irritable pathology, meaning I
would be able to perform a full examination.(9)
Past and current history: Although the patient’s progression of symptoms was
unclear, she does reveal that the pain and stiffness gradually got worse over
the first 6/12, which is very typical of patients in the first 2 stages of the
condition. Chronicity of the symptoms (>12/12) also supports this diagnosis.
(7,10) More specific questioning around the time course of symptoms is
needed. It is also possible for primary adhesive capsulitis to develop
insidiously following a minor shoulder trauma which explains why she noticed
the pain 4/52 post-trauma.(9, 3,11) Although the Cortisone injection was likely
administered to the subacromial region (superior deltoid area identified by
subject) for a different diagnosis, its location would have been effective in
frozen shoulder too.(28) This finding also confirms the inflammatory nature of
the condition.(9)
GHx: Her gender and age both fit nicely with the DX (most common between
40-60 year females).(10) Other nearby joints such as the elbow, cervical spine
and wrist had no significant symptoms suggestive of a pathology unrelated to
the GHJ. The fact that the patient is generally well and doesn’t complain of
pain elsewhere, indicates that the unlikeliness of a more sinister pathology
that would require further medical assistance.
Pathobiological process
The pathophysiology underlying adhesive capsulitis remains largely
undeciphered. Despite the confusion regarding the nature of the condition,
histological analysis has confirmed, both inflammation and reactive fibrosis
are involved. Although the initial stimulus is unknown, it appears that condition
progression is mediated by cytokines. (11) Adhesive capsulitis consists of four
phases. They are as follows:
Phase 1 (pre-adhesive) lasts for up to 3/12 and consists of
inflammatory synovitis (hypervascular hyperplasia of synovial cells and
T-cell infiltration) without fibrotic adhesions. Patients will report pain
without ROM restriction- fits the patient’s report of pain (during pilates)
as the first noticeable sign at 1/12.(9,11,10)
Phase 2 (adhesion) occurs between 3-6 months. During this stage, the
synovitic reaction worsens, fibrous adhesions are formed and there is
loss of joint volume due to capsular contracture. Severe pain (from
both synovitis and capsular adhesion to Humerus) is felt with restricted
active and passive movement secondary to scarring/reduced capsular
volume. This severity of pain matches the 10/10 pain reported by the
patient at approximately 6 months (before she saw GP).(12,13)
Typically between 6-12 months, patients experience phase 3 (adhesion
maturation) where pain is only at the end of range with a simultaneous
global reduction in ROM. Fibrotic synovium and dense scar tissue is
present with less synovitis. This phase matches the patient’s report that
the “stiffness is always there” but she explicitly notes the pain is only at
end range of the aggravating movements.
Phase 4 (chronic adhesion) is known as the “thawing” phase because
the patient experiences a progressive decline in pain with a
concomitant improvement in ROM. Similar pathology as in phase 3 is
present. This stage would represent the current phase the patient is in
as she reports slow improvement in pain and stiffness. (10,12,13)
The natural time course of each phase varies between individuals. (17)
Differential diagnosis
My main differential diagnosis is SLAP tear or rotator cuff tear.
RC tear has been included in my differential diagnosis because of the night
pain, loss of motion and history of trauma. She did not report a loss of
movement immediately following initial injury which indicates that she was
unlikely to have suffered a full thickness tear. The patient’s pain quality, pain
location and absence of weakness does not fit this Dx.(18) NAD imaging
results confirm the unlikeliness of this Dx (even calcific tendinopathy) as
ultrasound and x-ray would have identified such pathology.(19) Frozen
shoulder however, has insignificant radiologic findings.(4) It is also uncommon
for people under 60 years to suffer a cuff tear.(20)
Exacerbation of pain in “overhead” and “arm behind back” movements is very
typical in SLAP lesion patients, however, range of motion is usually
unaffected.(21)
The twisting mechanism of injury does not fit the SLAP diagnosis however, a
traction component may have occurred as she was trying to pull her arm out,
which can cause labral tears.(21) I needed to be more specific about my
questioning regarding the mechanism of trauma. Pain with lifting coin and
weighted objects may indicate labral tear as biceps are involved. Quality of
pain and posterosuperior location is indicative of a SLAP tear however,
absence of instability or clicking/locking is very atypical for this Dx.(6)
Prognosis
Due to the varied time course of the condition, recovery and phase times will
vary among individuals. What factors influence the time frame remain elusive
however, patients with more severe pain tend to have poorer prognosis than
those with mild or moderate pain.(22) Similarly, patients with a longer phase 1
are more likely to suffer a longer recovery.(23) It is unknown how long this
patient was in phase 1. More specific questioning around the progression of
her symptoms with specific times, would allow me to decipher the length of
stage 1, thus, her prognosis is difficult to determine. Her symptoms appear to
be following the typical time course, as it seems likely that she reached phase
2 just prior to 6/12 (noticed most severe pain) and is now in stage 4 (13
months). With this in mind, she would be likely to fully recover spontaneously
within 1-3 years, but on average she should expect resolution (no pain, no
stiffness) by 30 months.(7,17) There is possibility of slight ROM restriction
even upon “full” recovery. There is also a possibility of the contralateral
shoulder being affected up to 7 years after the initial onset. (7) (24)
Biopsychosocial factors
Biological: Primary adhesive capsulitis is known to develop insidiously
following minor upper extremity trauma. The patient's history of injury to the
ipsilateral shoulder may have contributed to the initiation of the frozen
shoulder via guarding of the injured limb (as discussed by the patient) that
results in simulated immobilization.(9,11) Other factors that contribute to her
diagnosis include her age and gender. Approximately 70% of those diagnosed
with adhesive capsulitis are female. In particular, it is most prevalent in
women aged 40-60 years. It is unknown why females are most affected,
however, hormonal changes occurring during the perimenopausal period (40-
60 years) are rumoured to play a role.(10,12)
Psychological: The patient reported guarding of the limb in fear of pain, which
is a fear avoidance behaviour. Such behaviour could potentially exacerbate
the problem by allowing random collagen deposition and fat infiltration.(9)
During the interview, I also noticed when she was gesturing, that she neglects
the injured side despite admitting that her condition has gotten better. I am not
sure if this is habitual or related to the fear of pain.
Social: As a bank teller, lifting coin is an essential task. She mentioned
struggling with this activity, which meant she was having to rely on others to
assist her-resulting in a loss of independence at work. She also reported
difficulties with her ADL’s in particular, those involving personal hygiene which
is an issue I would need to address in my patient education and treatment. I
would assess her further in these functional activities to determine if she
requires an Occupational Therapist because learning compensation strategies
(as she mentioned) to cope with these activities, is less than ideal.
Key physical examination findings
After investigating the patient's PROM, I would expect to see a capsular
pattern of limitation (limitation: external rotation>abduction> internal rotation).
This would indicate capsular pathology. I would also expect global reduction
in PROM with rigid capsular end-feel.(5,9,13,)
I would also expect to see a “shrug sign” (upward rotation of scapular when
abduction is <60 degrees) during active shoulder abduction. This finding
would rule out rotator cuff tear because it is not sensitive for that
pathology.(14) I would be observing where in the movement she gets the pain
to confirm the current phase. I predict that she is in stage 4, thus, I expect to
feel resistance prior to pain onset.(12)
To rule out SLAP tear, I would use the biceps load test 2 (arm abducted to
120 degrees) as it was found in a systematic review of all current SLAP tests,
to have the highest sensitivity of 89.7%.(15,16) With a negative result, I
would be reasonably certain the patient didn’t have a SLAP lesion. I wouldn’t
use Neer and Hawkins-Kennedy impingement tests as positive results will be
attained for both RC tear and frozen shoulder (due to capsular stretch).(9,3) A
more recent and accurate diagnostic test is the coracoid test which involves
palpation over the coracoid process. Provocation of pain is considered
positive for adhesive capsulitis. W ith respect to RC tear, calcifying tendonitis,
GHJ and AC arthritis, this test has a high sensitivity (0.96) and specificity
(0.87-0.89). If my patient tests negative, I would be very confident that my
diagnosis was incorrect, however, the opposite is true for a positive test.(26)
I would like to clear nearby joints by examining cervical spine and elbow.
Explanation to patient
Dianne, after having a look at the results from the physical exam, I have been
able to determine that you have adhesive capsulitis, which is commonly called
“frozen shoulder”. We aren’t exactly sure what triggers it however, what we do
know is that it follows 4 stages. During the first “pre-freezing” phase, the
shoulder gets really inflamed, so this is the time most patients start to notice
pain. As you get into the “freezing” stage, that inflammation gets worse and
the capsule that surrounds and protects the shoulder joint starts to thicken
and scar, forming attachments to nearby bones. These attachments make the
capsule tight, so it’s difficult to move the joint and extremely painful. Once
you’re in stage 3, that inflammation settles down and you’re left with the tight
joint that’s a little less painful. That scar tissue hasn’t begun to break down
just yet so you would have noticed that you were still feeling stiff a lot of the
time. You are likely in stage 4, the final stage, so you will gradually notice less
pain and stiffness with your daily activities up until full recovery. Most patients
regain full, pain-free function about 30 months after the initial onset of pain,
however, the time course is highly variable and it’s difficult to predict exactly
when each patient will recover. There is a chance that you may not regain all
of your original movement, however, we will work towards optimal recovery.
As for treatment options, doing some strengthening exercise for the muscles
surrounding the shoulder joint, will correct the muscle imbalance that occurs
during phase 3. This will hopefully prevent altered shoulder movement upon
recovery. To help ease pain and stiffness, I can perform “joint mobilizations”
which involves moving the joint in a pain free manner. These will also restore
some movement. (26,27)